((If trainee does not perform a full vital signs survey including temperature, BGL, and respiratory rate within the first 3 minutes — wife becomes increasingly distressed and states: 'He has been getting worse for an hour — why isn't anyone doing anything?'))

((If trainee accepts the family's heat exhaustion history and begins heat stroke management without further assessment — patient's GCS drops to 10 at the 5-minute mark, and wife reveals the productive green cough for the last 3 days))

((If oxygen is not applied within 3 minutes of patient contact — SpO2 drops to 85% on room air and RR increases to 32/min))

((If trainee applies a non-rebreather mask at 15L without considering COPD target saturations of 88–92% — facilitator prompts: 'You note from the history that Raymond is a known COPD patient on home oxygen. Does this change your oxygen delivery strategy?'))

((If trainee does not identify Red Flag Sepsis criteria (HR ≥130, SBP ≤90, RR ≥25, altered mental state, not passed urine in 6+ hours) — facilitator prompts after vitals are read: 'Looking at these observations together, what pattern do you recognise?'))

((If trainee does not pre-notify the receiving ED — facilitator at 8-minute mark states: 'Ambulance is 10 minutes away. Is there anything you should be communicating to the receiving hospital right now?'))

((If trainee does not document or verbalise Red Flag Sepsis at handover — facilitator prompts: 'What specific clinical flag will you communicate to the paramedic crew on handover?'))

This patient is suffering from Red Flag Sepsis secondary to a lower respiratory tract infection (pneumonia/infective COPD exacerbation), complicated by underlying COPD and significantly delayed recognition due to initial misidentification as heat exhaustion.

• Ensure scene and personal safety — don appropriate PPE including gloves and eye protection.
• Perform Primary Survey — confirm airway patent, identify increased work of breathing, identify circulatory compromise (rapid weak pulse, mottled cool peripheries, CRT 3s).
• Apply oxygen therapy — titrate carefully to target SpO2 88–92% given known COPD. Commence nasal cannula 2–4L/min; if SpO2 remains below 88%, step up to simple face mask 5–8L/min. Avoid uncontrolled high-flow oxygen to minimise CO2 retention risk.
• Perform full Vital Signs Survey — record GCS 12, RR 28, HR 132, BP 88/54, SpO2 88% RA, Temp 38.4°C, CRT 3s, BGL 4.2 mmol/L.
• Identify Red Flag Sepsis criteria in this patient: HR ≥130 (132), SBP ≤90 (88 mmHg), RR ≥25 (28), objective altered mental state (GCS 12, confused), not passed urine in ≥18 hours (6+ hours with catheter in situ — clinically significant), requires O2 to maintain SpO2 ≥88%.
• Formally identify and verbalise RED FLAG SEPSIS diagnosis — communicate clearly to crew and document on ePCR.
• Position patient semi-recumbent (position of comfort) — do NOT position flat due to respiratory compromise.
• Do NOT administer salbutamol at this stage — bronchospasm/wheeze is likely infection-driven. Salbutamol is outside EHS scope for COPD exacerbation (Intermediate Care and above). Provide supportive oxygen therapy only.
• Reassess vitals at 10 minutes — BP remains low at 86/50, HR has increased to 138, SpO2 improved to 93% on O2 NRB 15L but note patient is COPD — adjust oxygen delivery if SpO2 exceeds 92%.
• Pre-notify receiving ED immediately via State Operations Centre — communicate: patient identity, age, Red Flag Sepsis, haemodynamic compromise (BP 88, HR 132), altered GCS 12, COPD background, allergy to penicillin, estimated time of arrival.
• Ensure continuous patient monitoring — repeat full observations every 5 minutes given time critical status. Monitor for deterioration in GCS, increasing respiratory distress, cardiac arrest.
• Keep patient warm — use blanket to prevent hypothermia given peripheral shutdown.
• Reassure patient and wife continuously throughout — explain actions in calm, simple language.
• On ambulance arrival — perform IMISTAMBO handover explicitly communicating RED FLAG SEPSIS, haemodynamic instability, COPD background, penicillin allergy, and delayed recognition history.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Sepsis · Chronic Obstructive Pulmonary Disease (COPD) — Acute Exacerbation · Oxygen · Primary Survey · Pulse Oximetry · Glasgow Coma Scale (GCS) · Blood Pressure · Tympanic Thermometer · Blood Glucose Monitor